Request for period delay using Provera

NHS number (if known):

Height in centimetres (cm):

For example, 175

Weight in kilograms (kg):

For example, 60.6

Do you smoke?

Yes

No

Date next period is due:

Travel or special occasion details

Reason for period delay request:

Date of travel or occasion:

Duration of travel or occasion:

Medical history

To be completed to ensure suitability for Provera

Are you currently taking any medications?

Yes

No

Please list the medications you are taking:

Do you have any history of blood clots, stroke, or deep vein thrombosis (DVT)?

Yes

No

Have you ever been diagnosed with liver disease?

Yes

No

Are you pregnant or suspect you may be pregnant?

Yes

No

Do you have any known allergies to medications?

Yes

No

Please list your allergies to medications:

Are you currently using any form of contraception?

Yes

No

Please specify the form of contraception:

Have you previously used Provera to delay periods?

Yes

No

Did you experience any side effects?

Yes

No

Please specify the side effects:

Important information

Provera should be started three days before your period is due to be effective.
Provera is not a form of contraception. You should continue to use other forms of contraception to avoid pregnancy.

Acknowledgment and consent:

I understand that Provera is a prescription medication and should only be used under medical supervision. I confirm that the information provided is accurate and complete. I acknowledge that my GP will review my suitability for this medication and that I may be required to attend a consultation before it is prescribed.

Signature:

Date:

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Travel or special occasion details

Medical history

Important information